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CURRENT CONCEPTS
History Taking
Patients with rotator cuff failure can present with shoulder pain or significant weakness or stiffness or a combination of some or all of these presentations. From a diagnostic standpoint, it is reasonable to think that most of the patients presenting with pain after RCR fall into two broad categories: pain similar to preoperative pain and at the same site on the shoulder or pain at a different site (over the AC joint, subpectoral site of biceps tenodesis) in the same shoulder. A patient presenting with shoulder pain, which was similar in location and character to the preoperative pain can present as one of the three patterns and each of these has implications with respect to the diagnosis:
1. The pain never improved after surgery (wrong diagnosis with alternate etiology [Table 2], peri-operative RC failure, postoperative adhesive capsulitis)
2. Interval improvement in the symptoms but acute onset of pain in the index shoulder following a traumatic event (acute retear)
3. Interval improvement in the symptoms followed by insidious recurrence of similar pain in the index shoulder (chronic recurrent tear)
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Patients may also present with loss of strength and functional capabilities independent of shoulder pain. Loss of motion or stiffness can present early or late after RCR. Stiffness can manifest as loss of forward flexion or external rotation or internal rotation behind the back or a combination of these depending on the anatomic region of the capsule involved.
History of any wound complications including drainage from the wound, use of antibiotics postoperatively should be asked to determine the history of post op infection. The patient should also be asked relevant questions about the postoperative rehabilitation protocol (timing of active range of motion and strengthening exercises) and compliance with physical therapy.
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Physical Examination
A shoulder examination starts with a cervical spine examination to rule out cervical radiculopathy. Important physical examination findings on inspection include atrophy of the rotator cuff (RC) muscles in supraspinatus fossa and infraspinatus fossa, partial or complete deltoid atrophy (especially prior open or mini-open cuff repair), anterosuperior prominence of the humeral head, and scapular dyskinesia. The patient should be asked to point to the site of maximum pain before proceeding with palpation. Location of the pain and site of maximum tenderness is valuable in anatomic localization of the pain generating structure. Range of motion (active and passive) is usually tested next and includes evaluation of glenohumeral as well as scapulothoracic motion. Pseudoparalysis and anterosuperior escape should be specifically looked for, as these findings are important determinants for treatment decision-making. Strength testing of RC muscles will identify weakness of rotator cuff muscles (subscapularis, supraspinatus, infraspinatus and teres minor). Special tests for impingement (Hawkins and Neer sign), RC tear (bear hug, belly press, external rotation lag sign, horn blower sign, Jobes test), AC joint pathology (cross arm adduction, point tenderness, Obrien’s test) and biceps pathology (speeds, Yergason, Obrien’s test, subpectoral biceps test) should be performed.
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Table 2. Causes of Persistent Shoulder Pain in Patients Following a RC Repair
1. Cervical spine pathology-radiculopathy
2. Suprascapular neuropathy
3. Intra-articular conditions (glenohumeral arthritis, adhesive capsulitis, instability, labral pathology and biceps tendinopathy)
4. Extra-articular conditions (persistent subacromial impingement, acromio-clavicular arthritis, deltoid muscle insufficiency).
5. Failed rotator cuff repair
6. Referred pain (intraabdominal causes)
ISAKOS NEWSLETTER 2015: Volume I 35